Intramedulläre Nagelplatzierung mit perkutanen Kirschner-DrähtenDarstellung der Methode und klinische Beispiele

Unreamed nailing is an established method for internal fixation of femoral und tibial shaft fractures. The interlocking technique allows the stabilization of metaphyseal fractures, too, but the risk of malalignment increases. The "palisade method" presented here allows the precise positioning of the nail in the marrow cavity and works as a tool for successful minimally invasive nailing in the meta/epiphyseal region. The method is easy to use and suited particularly in combination with the UFN and UTN, but is in principal applicable to other nails, too. In contrast to the "Poller Screw" method developed by Krettek et al., no biomechanical augmentation of the osteosynthesis remains.     

"Biorigid" interlocking after unreamed intramedullary nailing of tibial shaft fractures

Between April 1996 and December 1999, 76 tibial shaft fractures were treated at the Department of Trauma Surgery of the Justus-Liebig-University in Giessen, Germany and the Department of Orthopedic Surgery of the University of Louisville, USA with a newly developed, unreamed, solid, small diameter tibial nail interlocked "biorigidly" with screws in grooves of the nail. 69 Patients were reviewed with a minimal follow-up period of 16 months. In 65 patients, the fractures united without exchange nailing, although four of these fractures showed a delay of healing. In further four cases, non-union occurred, one of which was associated with the only break of a nail located at a distal interlocking groove of the nail. In one patient, a late medullary infection so far has not recurred following treatment. In 358 implanted interlocking screws, no implant failure was observed. First clinical experience suggests that, especially due to the low rate of material fatigue, the biorigid nail is an alternative to other implants for unreamed intramedullary nailing of the tibia.     

Differentialindikation „offene“ oder „endoskopische“ Carpaltunnelspaltung

Zusammenfassung. Das Carpaltunnelsyndrom geh?rt zu den h?ufigsten peripheren Kompressionssyndromen, die dem Handchirurgen in der t?glichen Praxis begegnen. Es besteht in der Einengung des N. medianus im Carpalkanal. Symptome sind n?chtlich auftretende Kribbelpar?sthesien und Schmerzen, im sp?teren Stadium Hyp?sthesie in den vom N. medianus versorgten Gebiet und Thenaratrophie. Heute stehen uns offene, konventionelle und endoskopische Methoden der Spaltung des Carpaldachs zur Verfügung. Durch minimiertes Operationstrauma k?nnen die Patienten nach endoskopischer Carpaltunnelspaltung sehr früh mobilisiert werden. Diese Technik sollte vom erfahrenen, trainierten Chirurgen durchgeführt werden, um schwere Komplikationen zu vermeiden.      

Perkutane tibiotalare Arthrodese

We report on a 50-year-old female patient with bimalleolar fracture and subsequent posttraumatic arthrosis who was treated by minimally invasive nonresection tibiotalar compression arthrodesis using internal fixation and cancellous bone grafting. The advantages of this technique include minimal exposure of tissues, good control of the relationship between the tibia and the talus, and short hospital stay.     

Kapandji intramedullary wire osteosynthesis in proximal humeral fractures

For operative treatment of proximal humeral fractures minimal invasive techniques reduce the risk of iatrogenic damage of blood supply and periarticular scarring. Reported preliminary results are encouraging. We present our experience achieved with an intramedullary wire fixation adapted from a report of Kapandji in 1989. Between 3/95 and 6/00 29 patients were treated with this technique at our institution. All received early functional treatment. 14 patients (average mean age 56 years at time of trauma) who had a minimum follow up of 24 months (mean 36.4 months) and therefore allowed a preliminary conclusion regarding avascular head necrosis (AVN) were reexamined by use of the Constant Score and x-ray. We examined three unstable 2-part, four 3-part and seven 4-part fractures (5 of them valgus-impacted). The mean Constant Score at follow up was 70 points (31-86 points). We saw one total collapse of the humeral head because of AVN. In one patient the distal end of the wires led to a skin irritation and had to be shortened. We observed no secondary fragment displacement or non-unions. In our hands, this technique offers good results, even in valgus-impacted 4-part fractures of the elderly and allows internal fixation in little displaced but unstable fractures with the benefit of early functional treatment instead of longer immobilization. Based on the experience with intramedullary wiring the previously performed technique using threading wires was abandoned and the indication for primary arthroplasty considerably influenced.     

Verlassenes, Bewährtes und Aktuelles zur operativen Dünndarmileus-Therapie

Zusammenfassung. Wegen heterogener Patientengruppen und vielf?ltiger Ileus-Ursachen ist die Operationsindikation und die operative Verfahrenswahl beim Dünndarmileus schwer standardisierbar. Ein einheitliches Vorgehen bei der intraoperativen Handhabung des Darms (Ausstreifen, Einlage einer Darmschienung) und dem Bauchdeckenverschluss (Technik, Nahtmaterial) w?re wünschenswert. Die Adh?siolyse bleibt der h?ufigste chirurgische Eingriff. Chirurgische Techniken der Dünndarmplikatur finden weiterhin (bei einer relevanten Minderheit der Kliniken) Anwendung, wobei die Operation nach Noble weitgehend durch die Plikatur nach Child-Phillips und deren Varianten ersetzt wurde. Aufgrund des Fehlens kontrollierter Studien gibt es weder für Plikaturen noch für lange Sonden und andere operative Ma?nahmen gesicherte Indikationen oder Kontraindikationen. Angesichts von H?ufigkeit und sozio?konomischer Bedeutung des Dünndarmileus bleibt es eine wichtige Aufgabe für die Zukunft, dies zu ?ndern.      

Die Larynxmaske bei Adenotonsillektomie bei Kindern Gefährliche Spielerei oder medizinischer Fortschritt?

Anaesthesia both for adenotomy (AT) and for tonsillectomy (TE) frequently presents a challenge. On one hand, children scheduled for adenotomy often have upper airway infections and are thus at risk of laryngo- and bronchospasm; on the other hand the ENT surgeon and the anaesthetist have to share the "workspace" in the patient's mouth. Since the succinyl choline debate in the early 1990s, the question of the best muscle relaxant has gone hand in hand with that of the most appropriate means of securing the airway. The concept of the laryngeal mask as airway was initially greeted with scepticism. Following several years' use of the mask for this purpose in AT and TE in young children, we report our experience and summarise the literature on this topic. The laryngeal mask represents a safe alternative to intubation, provided there is close cooperation with the ENT surgeon.     

Technik der gedeckten Refixierung der distalen Bizepssehne

From May 1999 to November 2001 an anatomical attachment of a ruptured distal biceps tendon to the radial tuberosity was performed through a limited anterior approach in 8 male patients with an age of 37 to 47 years. Through a small incision in the cubital fossa (3-4 cm) the remaining synovial sheet of the biceps tendon was followed to insert absorbable anchor hooks into the radial tuberosity. The distal biceps tendon then was anatomically reattached. Instruments for arthroscopic Bankart-repair were used. There were no specific complications like neurovascular damage or significant functional impairment. The contour of the biceps muscle was restored in all cases. 3 out of 7 patients developed mild heterotopic ossifications without functional deficits. In our experience the presented technique is a possible minimal invasive procedure of distal biceps tendon repair without major complications and with good functional results.     

Die Tracheostomie Indikationen, Methoden, Risiken

Tracheostomy is one of the oldest procedures in surgery. Although it was traditionally used for treatment of upper airway stenosis, the primary surgical indication is now in the long-term intensive care unit patient. Here, the aims are avoidance of damage to the larynx, earlier weaning from artificial respiration and improved nursing care. Apart from the conventional operating method, minimally invasive procedures have been increasingly employed. More than 20,000 ICU patients per annum are now treated in Germany by these modern methods. Common features of these procedures are the initial puncture of the trachea with subsequent dilatation of the puncture channel. Current meta-analyses of prospectively randomised studies show a lower complication rate than with conventional methods. Furthermore, serious sequelae such as tracheal stenosis are rare in the long-term course. However, conventional operative tracheostomy still has its place, particularly in circumstances where the new methods are contraindicated.     

Retrograde locking nail osteosynthesis of distal femoral fractures with the distal femoral nail (DFN)

Non-operative treatment with immobilization or isometric traction has been abandoned as treatment for fractures of the distal femur at the end of the 1960ies. The technique of open reduction and internal fixation with a condylar plate as suggested by the AO has been the golden standard since the 1970ies. However, anatomic reconstruction of the condylar region with interfragmentary screw fixation and axial realignment of the femur shaft with a plate are challenging procedures especially in the presence of severely compromised soft tissues and put periosteal blood supply at risk. Soft tissue complications, axial malalignment and delayed fracture healing times led to the consideration of alternative techniques, such as intramedullary nailing which has been practiced with success since the 1940ies by Gerhard Küntscher and colleagues for femoral shaft fractures with minimal complication rates and improved results after closed reduction. The era of retrograde femoral nailing began with the systematic approach through the intercondylar notch by Green. This paper reviews the biomechanical properties, indication, technique as well as potential hazards and pitfalls of fracture management with the AO "distal femoral nail" (DFN). With appropriate application this technique is suitable for all fractures of the distal third of the femoral shaft including highly instable bicondylar fractures without damage to the soft tissues and the knee joint.     

Dopplersonographisch unterstützte Hämorrhoidenarterienligatur Eine neue Therapie bei symptomatischen Hämorrhoiden

In 1995, Morinaga et al. (Japan) reported on a new technique in the treatment of hemorrhoids. We report the results of our first 105 patients thus treated. By a specially designed proctoscope coupled with a Doppler transducer, the hemorrhoidal arteries are looked for and ligated. All stages of hemorrhoid were treated. This method is painless, successful, and has a low rate of complications. It is for outpatients and is an alternative to all other methods in the treatment of hemorrhoids.     

Sprechfunk im Notarztdienst

For the participation in the official radiotelephony of those German authorities and organisations which are in charge of civil security and protection (Behörden und Organisationen mit Sicherheitsaufgaben, BOS), an official instruction is necessary. During an emergency run, the radio communication is usually carried out by the paramedics. In order to increase the safety of driving during emergency runs and with regards to the prohibition of the use of cellular phones while driving (planned by the German government for summer 2000), it appears to be wise for emergency physicians to get in touch with this important part of daily work in emergency service. Next to the Police and Fire Departments, the authorities and organisations mentioned above are the emergency medical services and disaster relief organisations. For all these organisations the Federal Republic of Germany runs a common radio network (ultra high frequency; wavelength: 4 meters). This radio network is regulated by the guideline DV 810.3 released by the Deutsche Bundespost and the Bundesamt für Post und Telekommunikation (BAPT). It is recommended for emergency physicians, especially if they're working as a chief of the German physician manned emergency system, to be instructed in the correct use of this German security radio network.     

Die laparoskopische Splenektomie: Neue Techniken und Indikationen

Over the recent years laparoscopic splenectomy has become the preferred approach for the treatment of many conditions requiring splenic removal. At first limited to small spleens and to benign hematologic disorders, this procedure is now used for a variety of indications. Enlarged spleens are possible to be removed laparoscopically, although this is still a demanding procedure. Two factors facilitated the technique and contributed to its wide acceptance: 1) Change in the technique originally used, by positioning the patient in right lateral decubitus, and approaching the spleen from a postero-lateral direction. 2) The development of new technologies to dissect and divide tissues and vessels, including the ultrasonic shears and the laparoscopic linear stapler. In this article we review the current indications for laparoscopic splenectomy, as well as the techniques to accomplish this procedure.     

Die Herniotomie nach Shouldice The Shouldice repair

Zusammenfassung. Die Herniotomie nach Shouldice hat sich zur klassischen offenen, anatomischen Geweberekonstruktion entwickelt. Die Operation ist ein wesentlicher Bestandteil im Arsenal jedes Chirurgen, da in kritischen Situationen, wie bei Strangulationen, und Versagen von spannungsfreien prothetischen Versorgungen und laparoskopischem Vorgehen das Verfahren nach Shouldice angewandt werden mu?. Bei ad?quater Durchführung setzt die Herniotomie nach Shouldice Ergebnisstandards, die es mit den anderen Techniken zu erreichen gilt. Andere besondere Vorteile dieser Technik sind: Sicherheit, der Einsatz von Lokalanaesthetica, ein unproblematischer postoperativer Verlauf und die beste Kosteneffizienz aller eingesetzten Techniken.      

Supportive Composite- Hybridfixation perkutan verschraubter Tibiakopffrakturen

Alternativ zu aufwendigen internen Stabilisierungsverfahren bietet die supportive Composite-Hybridfixation bei Tibiakopffrakturen eine neue Perspektive der frühfunktionellen Nachbehandlung mit seltenem Repositionsverlust bei frühzeitiger Vollbelastung. Sie wird bevorzugt bei geriatrischen und alkoholabh?ngigen Patienten sowie bei Frakturen mit h?hergradigem Weichteilschaden eingesetzt.      

Die Versorgung epiphrenischer Ösophagusdivertikel in laparoskopisch-transhiataler Technik

Introduction. The operative treatment for epiphenic diverticula is usually performed via thoracotomy or laparotomy. Patients and methods. Alternatively we describe the feasibility of a laparoscopic transhiatal approach in three consecutive symptomatic patients with four epiphrenic diverticula. In all cases, the diverticula were completely resected laparoscopically in combination with an esophagomyotomy and a posterior partial fundoplication. Results. The three patients showed uneventful postoperative courses with a speedy recovery and are symptom-free after a follow-up of 22–41 months. Conclusion. Our results demonstrate that laparoscopic transhiatal procedure in patients with symptomatic epiphrenic diverticula can be performed safely, effectively, and gently.     

Laparoskopische colorectale Chirurgie – Versuch der Bewertung einer neuen Technologie

Zusammenfassung. Ziel der Untersuchung war, die Wertigkeit der laparoskopischen colorectalen Chirurgie zu untersuchen. Von 131 Patienten wurden 80 (61 %) laparoskopisch operiert. Bei 13/93 (14 %) wurde konvertiert. 47 (59 %) litten an einem Carcinom, 41 wurden kurativ operiert. Zum Vergleich dienten 48 offen operierte Patienten. Die Komplikationsrate war nach laparoskopischer Technik reduziert, Reoperationen waren nicht notwendig, die Rekonvaleszenz war rascher; erste Nahrungsaufnahme und erster Stuhlgang traten früher auf. Die Krankenhausverweildauer war verkürzt (15,3 vs. 8,1 Tage). Die Schmerzen waren in Ruhe und Bewegung signifikant geringer. Resektatl?nge, Resektionsabst?nde und Anzahl der entfernten Lymphknoten waren gleich. Portmetastasen wurden nicht beobachtet. Eine verminderte Morbidit?t, ein verkürzter Krankenhausaufenthalt, verminderte Schmerzen, eine schnellere Rekonvaleszenz bei ad?quater Radikalit?t und akzeptablen Kosten sprechen für die laparoskopische Technik.      

Neuer Analretraktor für handgenähte coloanale Anastomosen

Zusammenfassung. Um eine handgen?hte coloanale Anastomose sicher und ohne Sphincterschaden durchführen zu k?nnen, ist eine ad?quate und atraumatische Darstellung des Analkanals erforderlich. Wir berichten hier über die Modifikation eines Analspreizers, der die Darstellung des Analkanals und das Handhaben des Fadens w?hrend der coloanalen Anastomosen vereinfacht. Dieses modifizierte Ger?t wurde systematisch bei allen coloanalen Anastomosen und transperinealen Eingriffen, die in unserer Klinik 1997 durchgeführt wurden, verwendet. Die ausgezeichnete übersicht über den Analkanal und die einfache Handhabung beschleunigen und vereinfachen die Durchführung coloanaler Anastomosen.